Just Culture: A 2020 Update and Case Studies

1 © 2020 TMIT Global TMIT Global

March 19, 2020 Webinar Month 137

For resource downloads go to:

www.safetyleaders.org

Just Culture:

A 2020 Update and Case Studies


Charles Denham, MD Chairman, TMIT Global

TMIT High Performer Webinar March 19, 2020 Webinar Month 137

Welcome


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TMIT Purpose Statement

Our Purpose:

We will measure our success by how we protect and enrich the lives of families…patients AND caregivers.

Our Mission:

To accelerate performance solutions that save lives, save money, and create value in the communities we serve and ventures we undertake.


Disclosure Statement The following panelists certify that unless otherwise noted below, each presenter provided full disclosure information; does not intend to discuss an unapproved/investigative use of a

commercial product/device; and has no significant financial relationship(s) to disclose. If unapproved uses of products are discussed, presenters are expected to disclose this to

participants. None of the participants have any relationship medication or device companies discussed in their presentations.

David Marx, a pioneer of the Just Culture movement. The firm originally addressed safety issues and human factors in aviation and offered expertise in post-event investigation and analysis. With

the unique combination of systems engineering, human factors, and the law, Marx adopted and expanded the concepts of ‘Just Culture’ to help improve the management of human error. He has

nothing to disclose.

Heather Foster, RN, is a practicing nurse in Colorado who has championed the cause of patient and caregiver safety with great courage and faith after her patient died a preventable death. She

receives the Pete Conrad Global Patient Safety Award for her steadfast support of speaking truth to power, for championing patient safety at great personal risk, and for representing the masses

of frontline caregivers who feel at personal risk and powerless to stand up for their patients. She is one of expert advisors to The Healthcare Innocence Project, a program founded on the

principles of the Innocence Project which 25 years ago pioneered using a “new technology” of DNA testing to help exonerate the wrongly convicted. The Healthcare Innovation Project uses the

currently “new technology” of electronic medical and human resources records that can be used to protect patients, caregivers, and their families from error and administrative fraud. Heather

Foster is developing educational resources to help caregivers deal with preventable adverse events, ethical human resources best practices relating to frontline caregivers, and case studies in

healthcare ethics related to governance interactions with frontline caregivers. Working with global educators, she is helping developing programs to help other caregivers like her deal with some

of healthcare’s most challenging problems in patient and caregiver safety. She has nothing to disclose.

Arlene Salamendra is a former Board member and Staff Coordinator of Families Advocating Injury Reduction (FAIR). A number of years ago, she was the subject of a preventable medical error.

Since that time, she has devoted a portion of her time to giving support to other patients who have been injured or have lost a loved one, and rectifying the systems errors that lead to preventable

medical errors. She is a member of the TMIT Patient Advocate Team. She has nothing to disclose.

Charles Denham, MD, is the Chairman of TMIT; a former TMIT education grantee of CareFusion and AORN with co-production by Discovery Channel for Chasing Zero documentary and Toolbox

including models; and an education grantee of GE with co-production by Discovery Channel for Surfing the Healthcare Tsunami documentary and Toolbox, including models. HCC is a former

contractor for GE and CareFusion, and a former contractor with Siemens and Nanosonics, which produces a sterilization device, Trophon. HCC is a former contractor with Senior Care Centers.

HCC is a former contractor for ByoPlanet, a producer of sanitation devices for multiple industries. He does not currently work with any pharmaceutical or device company and has not done so for

more than 5 years. His current area of research is in threat management to institutions including conflict of interest, healthcare fraud, and continuing professional education and consumer

education including bystander care. Dr. Denham has been a collaborator with the late Professor Christensen at Harvard Business School.


Speakers and Reactors

Dr. David Marx Dr. Charles Denham Arlene Salamendra Heather Foster


Voice of Patient and Family

Arlene Salamendra

Former Board Member and Staff Coordinator, Families Advocating Injury

Reduction (FAIR)

TMIT Global Patient Advocate Team Member

Plano, IL

TMIT High Performer Webinar

February 20, 2020



TMIT High Performer Webinar

March 18, 2020

Webinar 137

In the News Update and

February 2020 Webinar Recap

© 2006 HCC, Inc. CD000000-0000XX 13 Med Tac Bystander Rescue Care

Meaningful Use is dead. Long live something better!

Flattening the Curve: Avoid the Surge

Our Healthcare Capacity

www.GlobalPatientSafetyForum.org Emerging Threats Community of Practice

http://www.globalpatientsafetyforum.org/

Readiness for Epidemics including preparedness for testing and

volume surges

© 2006 HCC, Inc. CD000000-0000XX 16 © 2020 TMIT

Cardiac Arrest

Meaningful Use is dead. Long live something better! High Impact Care Hazards to Patients, Students, and Employees

Opioid Overdose

Common Accidents

Bullying

A Medical-Tactical Approach undertaken by

clinical and non-clinical people can have

enormous impact on los of life and harm

from very common hazards:

• High Impact Care Hazards are frequent,

severe, preventable, and measurable.

• Lifeline Behaviors undertaken by anyone

can save lives.

Choking & Drowning

Anaphylaxis

Major Trauma

Transportation Accidents

16

Med Tac

Story Article

Active Shooter

Healthcare Article

AED & Bleeding

Control Gear Article

Rapid Response

Teams Article

Battling Failure to Rescue

Automated External

Defibrillator

& Bleeding Control

Gear Placement

17

17

www.MedTacGlobal.org

Bystander Rescue Care

for Failure to Rescue

18

18

www.medtacglobal.org/coronavirus-response/.org

19

Emerging Threats

Community of Practice

Med Tac Bystander Rescue Care


CareUniversity Series

Speakers

Reactors

Jennifer Dingman

Dr. Charles Denham Chief William Adcox Dr. Gregory Botz

Dan Ford Randy Styner Dr. Chris Fox Tom Renner David Beshk

20

20

© 2006 HCC, Inc. CD000000-0000XX 21 © 2020 TMIT Global TMIT Global

In The News …

August 20, 2018

Unfortunately, threats to the integrity of U.S. biomedical research exist. NIH is aware that some

foreign entities have mounted systematic programs to influence NIH researchers and peer

reviewers and to take advantage of the long tradition of trust, fairness, and excellence of NIH

supported research activities. This kind of inappropriate influence is not limited to biomedical

research; it has been a significant issue for defense and energy research for some time. Three

areas of concern have emerged:

1. Diversion of intellectual property (IP) in grant applications or produced by NIH supported

biomedical research to other entities, including other countries;

2. Sharing of confidential information on grant applications by NIH peer reviewers with others,

including foreign entities, or otherwise attempting to influence funding decisions; and

3. Failure by some researchers working at NIH-funded institutions in the U.S.

to disclose substantial resources from other organizations, including foreign

governments, which threatens to distort decisions about the appropriate use of NIH funds.

“We recently reminded the community that applicants and awardees must disclose all forms of

other support and financial interests, including support coming from foreign governments or-

other foreign entities.”

“We also expect and encourage your institution to notify us immediately upon identifying new

information that affects your institution's applications or awards. Lastly, we encourage you to

reach out to an FBI field office to schedule a briefing on this matter.”

DEPARTMENT OF HEALTH

& HUMAN SERVICES

Public Health Service

National Institutes of Health

Bethesda, Maryland 20892

LETTER TO THOSE ORGANIZATIONS RECEIVING FEDERAL GRANTS

© 2006 HCC, Inc. CD000000-0000XX 22 © 2020 TMIT

In The News …

A Disclosure Form for

Work Submitted to Medical Journals A Proposal from the International Committee of Medical Journal Editors

SOURCE: New England Journal of Medicine, February 13, 2020

February 13, 2020

Many factors, including

professional and personal

relationships and activities, can

influence the design, conduct, and

reporting of the clinical science

that informs health care decision.

The potential for conflict of interest

exists when these relationships

and activities may bias judgement.

Many stakeholders — editors, peer

reviewers, clinicians, educators,

policymakers, patients, and the

public — rely on the disclosure of

authors’ relationships and activities

to inform their assessments. Trust

in the transparency, consistency,

and completeness of these

disclosures is essential.

© 2006 HCC, Inc. CD000000-0000XX 23 © 2020 TMIT

In The News …

23

Patient Safety and COI Stories Being Followed

Tampa Bay Times Reports:

• Deaths of children in 1 in 10

undergoing CV Surgery at

JH All Children's

• Mutilation of children in

burn unit in Maryland

• Cover up of harm

• Retaliation against

whistleblower MD

• Patient Safety Issues in all

Johns Hopkins hospitals

• Whistle blower law suit

• Multiple malpractice suits.

• Regulatory problems

• Oversight letting team of

doctors make unannounced

visits

NYT & Propublica Reports:

• Conflicts and large payments

to Chief Med Officer – resigns

• CEO with conflicts, vote of

non-confidence – resigns

• Board Members own equity in

start up with special deals.

• Revision of conflict of interest

policies.

• Top executives barred from

serving on corporate boards

or investing in start-ups

Propublica &

Houston Chronicle Reports:

• Cardiac Complications

• Undeclared financial conflicts

of interest

• Allegations of exaggerated

quality program to lure

patients.

• Transplant program shut

down based on reporting.

• Leadership restructuring

• State and federal officials

enforcing safety standards.

• 08-08-19 Feds Cease Greater

Oversight Of Baylor St. Luke’s

Medical Center Initiated After

Patient Death

New York Times &

Washington Post Reports:

• Falsification of research in

cardiac stem care.

• Scientific misconduct

• 31 Articles Retracted

• Many patients treated

• Unknown impact of product

used in patients treated.

• Hospital paid to settle

allegations.

• Hospital pays $10M to settle

Tennessean & Beckers Hospital

Review Reports:

• Nurse medication error during

imaging with patient death

• Electronic medication

dispensing cabinet

safeguards overridden.

• Nurse indicted for reckless

homicide for fatal error.

• State Health Officials decided

no reason to discipline or take

action against nurses license.

© 2006 HCC, Inc. CD000000-0000XX 24 © 2020 TMIT

In The News …

24

Medscape Reports:

• Duke Settles Doctored Data

Lawsuit for $112.5 Million

• Duke Whistleblower Gets

More Than $33 Million In

Research Fraud Settlement

• William Foster, who ran the

lab where the data were faked,

studied the effects of

pollutants on the lungs of

mouse models.

• Thomas alleged that Duke had

won some 50 grants from the

NIH

The Washington Post Reports:

• Baltimore Mayor Pugh involved in

self-dealing book scandal for

hundreds of thousands of dollars.

• UMMS Board Chairman announced

the board's unanimous decision

March 21 to have CEO Robert

Chrencik take a leave of absence.

• Resignations of three UMMS,

including Baltimore Mayor Pugh.

• Hours before Mr. Burch notified the

public of Mr. Chrencik's leave of

absence, the Maryland House of

Delegates unanimously fast-tracked

bill to overhaul UMMS' 27-member

board of directors.

• Kaiser Permanente paid Pugh more

than $100,000 for 20,000 copies of her

books during a period when the

company was seeking a lucrative

contract to provide health benefits to

city employees.

Medscape Reports:

• Between 2011 and 2019

William Roper, failed to

disclose his seats on the

boards of major corporations.

• At the same time, those

corporations did business

with the state, records show.

• Roper has served on the

board of directors of DaVita,

Inc.

• Roper also a member of the

board of directors of three

successor companies in the

pharmacy benefits

administration industry.

• None of his corporate board

service was disclosed on

state ethics forms.

Tampa Bay Times Reports:

• Johns Hopkins All Children’s

faces record state fines.

• The planned $800,000 penalty is

the latest fallout from problems

in the hospital’s heart surgery

department.

• State regulators intend to hit

Johns Hopkins All Children’s

Hospital with some of the largest

fines levied against a Florida

hospital in recent memory,.

• The Times found that surgeons

in the hospital’s Heart Institute

made serious mistakes and their

procedures went wrong in

unusual ways. It also found that

the hospital continued to

perform heart surgeries for

years after frontline workers

raised safety concerns to their

supervisions.

New York Times Reports:

• Director of M.I.T.’s Media Lab

Resigns After Taking Money

From Jeffrey Epstein.

• M.I.T. official, Joichi Ito, left

the boards the MacArthur

Foundation, the John S. and

James L. Knight Foundation,

and The New York Times.

• He “stepped down after the

disclosure of his efforts to

conceal his financial

connections to Mr. Epstein,

the disgraced financier who

killed himself in a Manhattan

jail cell last month while facing

federal sex trafficking

charges”. acknowledged last

week that he had received $1.7

million from Mr. Epstein,

including $1.2 million for his

own outside investment funds.


© 2006 HCC, Inc. CD000000-0000XX 25 © 2020 TMIT

In The News …


Beth Israel COI & Theft:

• Chinese cancer researcher,

confessed that he had

planned to take the stolen

samples to Sun Yat-sen

Memorial Hospital, and

publish the results under his

own name.

• Customs officers officers

found what they were looking

for: 21 vials of brown liquid —

cancer cells.

• The researcher admitted he

had taken the samples to

publish the work under his

own name.

January 29, 2020

Joshua and Beth Friedman

University Professor

Harvard University

Department of Chemistry

and Chemical Biology

Harvard Chemistry Chairman

Under Investigation Is a Giant of His Field Charles Lieber is charged with lying to U.S. authorities

about taking millions of dollars from the Chinese government

The Harvard University professor arrested and charged with

lying to U.S. authorities about taking millions of dollars from

the Chinese government is considered one of the fathers of a

specialized field in nanotechnology. Charles M. Lieber has led

a research lab at Harvard for nearly 30 years and generated in

excess of $15 million in grants from government agencies

since 2008. He was rated the top chemist of the aughts by one

analytics organization that rated academic productivity.

Former research assistants in his lab said Wednesday they

were shocked by his arrest and even surprised by his alleged

association with the Chinese program that allegedly paid him

$1.5 million that he didn’t report. Mr. Lieber was remanded to

federal custody. He is charged with a single felony count for

making false statements to U.S. government agencies.

© 2006 HCC, Inc. CD000000-0000XX 26 © 2020 TMIT

A New Program

The Healthcare Innocence Project builds on the successful

model of The Innocence Project. Where it used the new

technology of DNA 25 years ago, we will use the new technology

of electronic records and the digital DNA in the E.H.R. and

administrative records to protect the medical identity of patients

and the professional identity of caregivers. Both patients and

caregivers may be unjustly treated through intentional or

unintentional behaviors of insiders or outsiders of healthcare

organizations. They include weaponization of HR, sham peer

review, discrediting patients and families after healthcare

accidents, or unjust harm through outsider cybersecurity

issues.

The Healthcare

Innocence Project

26

www.HealthcareInnocenceProject.org

http://www.healthcareinnocenceproject.org/

© 2006 HCC, Inc. CD000000-0000XX 27 © 2020 TMIT

Healthcare Innocence Project

27

• Mis-information: when false information is shared, but no harm is meant.

False Narratives & Weaponizing Information

• Dis-information: when false information is knowingly shared to cause harm.

• Mal-information: when genuine information is shared to cause harm, often by moving information designed to stay private into the public sphere.

Source: Claire Wardle and Hossein Derakhshan “Information Disorder”


Jeanne M. Huddleston, MD, FACP, FHM

Hospitalist

Former Chair Mortality Review Subcommittee

Mayo Clinic

Rochester, MN

TMIT Global High Performer Webinar

February 20, 2020

Webinar 135

Pre-presentation Questions & Comments

Continuous Organizational Improvement and Learning: A Modified Delphi Approach Connecting Reviews to Meaningful Change

MultiLens Reviews

MultiLens Group Consensus

Cluster Analysis

Common Thread

Reviews

SBAER & QI

project

definition

01 03 05

02 04

Multidisciplinary,

multispecialty case

discussion meetings turning

issues into OFIs

Group Consensus

Multidisciplinary,

multispecialty review findings

and opinions

MultiLens Reviews

What do the patients in the

cluster have in common?

Common Thread

Reviews

Which patients fell through

the same vulnerable crack in

the system?

Cluster Analysis

Common threads

become actionable

requirements for

SBAER & successful

project charter.

QI project

definition

Finalize data

Detect patterns

Create

requirements

Actionable

information

Gather data

© HB Healthcare Safety, SBC (2016-2019)

30 © 2020 TMIT

64%

12% 13%

5% 4% 1% 1% 0% 0% 0%

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

Very

Strongly

Agree

10

Strongly

Agree

9

Agree

8

Agree

7

Very

Strongly

Disagree

1

Disagree

3

Strongly

Disagree

2

Neutral

6

Neutral

5

Negative to

Neutral

4

94% Agreed and 76% Strongly or Very Strongly Agreed,

and 64% Very Strongly Agreed

Anonymous Survey Questions

Source: TMIT High Performer Webinar Series; Mortality Reviews and Patient Safety: A 2020 Update – February 20, 2019

I would like another webinar on

MORTALITY REVIEWS by COLLABORATORS

31 © 2020 TMIT

• Action planning after opportunities are identified

• Admin support and lack of for culture change

• Administrative support

• Any topic, this was so insightful

• Anything

• Anything quality related to help take care of patients better.

• Benefits of risk and quality committee involvement for OFI and issues.

• Best team approach and phases as well as data for trend analysis

• Capturing SOI/ROM

• Changing culture to just culture and removing punitive mindset. Helping

senior leaders understand the infrastructure that is required for a robust

quality and safety program. One FTE where six are needed just doesn't cut it.

• Classifying and quantifying system level changes, identifying the rate of

adverse events, learning to identify unanticipated deaths

• Common threads; focus areas

• Continue with the same educational line, I love how it addresses that if we

don't fix the omissions, there will be more burn out and severe depression in

medical staffs

• Creating a mortality review committee and examples of review format and

training.

• Culture of safety

• Deep dive into the review methodology

• Deeper into risk adjusted mortality indexes

• Diagnostic errors

• Disease specific concerns

• Do you have a worksheet or allorhythmia that you recommend to initiate the

mortality reviews?

• Ed mortalities

• Emergency dept mortality reviews

• End of life

• End of life - how can we increase awareness about palliative care vs. Hospice

care among our communities (patients, families and even our internal

professional healthcare staff). So few people have a good understanding or

awareness of how beneficial both end of live specialties are and that they

should get these specialties involved earlier in their care journey. The majority

either don't consult palliative care nor refer to hospice OR they do, but it's a

few days prior to the day that the patient dies.

• End of life care, advanced directives

• Expand on the actual process or data points reviewed during mortality

reviews.

• Expand on the interdisciplinary reviews, how to begin

• Finding the common thread

• Further drill down into best key metrics and data points to capture


The topics I wish to have covered in another webinar on

MORTALITY REVIEWS

32 © 2020 TMIT

• General

• Getting started

• Getting started with mortality review. More detail on how to start.

• Great information

• HACS/hai's

• Hear from the staff that are doing the work, the process, tools overcoming

barriers and staff that are disengaged

• How do you work with organizational barriers to have providers involved?

Such as RN restrictions on spending additional time, MDS over scheduled,

prioritization by management, dealing with independent MDS?

• How to achieve these robust reviews. Role of student monitoring in patient

safety

• How to get leadership engaged in understanding bedside caregivers need to

have the tools to provide the best care; free from errors

• How to moving from discovery to improvement

• How to perform a motility review

• I would like to hear more from this presenter.

• Implementing change

• Improved care for the prison population

• Incorporating safety into traditional M&M

• Interested in a series on what dr. Huddleston is learning

• Interested in hearing more about why we need to shift the focus beyond

preventability. Would this change event classification?

• Intraoperative injuries and deaths

• Is there a mortality review template you could share? Also, how do you go

about obtaining by-in from providers related to mortality review?

• Items to look for while doing mortality reviews, trends, high risk items.

• Learners vs doers

• Managing critical patients issues up to leaders

• Medication error

• MI mortality

• More about the review process

• More details of the safety learning system

• More info on SBAER, case studies utilizing clutter and common thread

analysis

• More information about focusing on opportunities instead of

preventability/causality. This is very interesting

• More inf

• More on how to address OFI

• More on lifting up the blind spots to leaders uncovered from mortality reviews

using your framework.



MORTALITY REVIEWS

33 © 2020 TMIT

• More specifics on how how to do these chart reviews, perhaps a form that

prompts people to look for specifics? Also what types of findings and how

those are put into practice.

• Mortality review data collection

• Mortality review data collection

• Mortality review process

• Moving from identified OFI to improvement

• Near misses

• Nurse quality outcomes specialist escalating cases for physician review.

• Nurses workplace violence

• Opioid events

• Palliative care

• Palliative care delay

• Pediatric mortality

• Peer review best practices

• Practical tips for implementation of review system; suggestions to help

identify and elevate the "below the iceberg" problems to leadership; how did

you structure your team & engage the disillusioned; practical ideas for

systemic learned helplessness

• Preventable complications

• Process

• Quality measures in total cost of care environs

• Readmissions

• Recognizing medical problems in patients admitted for behavioral health event

• Recognizing physical aspects of burnout

• Report building, review process & escalation, inclusion of medical staff

• Review of the application of the CMS guidelines for mortality exclusion charts.

• Screening/review forms

• Sepsis

• Templates for mortality review & database

• The connection with earlier palliative intervention. What evidence is there that

earlier palliative involvement will positively affect mortality rates or

readmissions.

• Tips to improve mortality

• Tools for analysis

• What do the nurse reviewers look for when reviewing a mortality and is that

shared with the MD or do they review individually then compare?

• What was done to improve several issues?

• When improvements are identified in your mortality reviews, how do those get

handled or funneled through? Who's responsible? Many times improvements

are identified and then there's the...Then what?

• When palliative care consult should be involved; aspiration pneumonia; sepsis



MORTALITY REVIEWS

34 © 2020 TMIT

35%

9%

19%

9% 6%

12%

6% 3%

1% 0%

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

Very

Strongly

Agree

10

Strongly

Agree

9

Agree

8

Agree

7

Very

Strongly

Disagree

1

Disagree

3

Strongly

Disagree

2

Neutral

6

Neutral

5

Negative to

Neutral

4

72% Agreed and 44% Strongly or Very Strongly Agreed,

and 35% Very Strongly Agreed

Anonymous Survey Questions


I am interested in a series of webinars on

BURN OUT

35 © 2020 TMIT

• After involved in patient safety event

• Bouncing back after burning out

• Burn out resulting from staffing shortages

• Burn out wouldn't be a topic that I'm extremely interested in at this point.

• Clinician burnout and moral distress among nurses

• Compassion fatigue and the impact

• Difference between physicians versus other disciplines and the differences in approach

• Finding a balance

• Healthcare providers, I see much about physicians and nurses, what about the interdisciplinary team?

• How burn out impacts patient safety and interaction with colleagues.

• How to address staffing issues

• How to measure burn out contributing to safety events-what questions to ask when investigating

• How to not get los

• How to prevent healthcare worker burn out to maintain long term employees

• I believe burn out is a wonderful topic, that is very important to the global organizations. I am not in a

place to focus on more than one topic aat this time, so mortality is my focus.

• I would like to see the topic expanded beyond physician burnout

• Identification

• Improving quality by avoiding burnout

• Increasing education on additional staff

• Increased staff demands amid decreased staffing

• Lack of communication and emotional reasons for burnout

• Lack of support

• Never enough. Its never enough staff to comfortably perform gentle care. It's never enough of your

dedication to administration. It just seems like it is never enough.

• Not sure but would really like to see safety study repeated since technology added. Has it helped or

added different issue?

• Not sure, but an important topic in what we do.

• Nurse burn out

• Nurses, sleep deprivation and caffeine

• Nursing shortage

• Patient safety due to errors from burn out

• Prevention of burnout, remedies

• Provider engagement

• Recognition, prevention, intervention and honestly, what can we really do about it when we have no

budget. Thanks!

• Recognizing burnout in advance

• Recognizing signs. How to create more whitespace. How to recognize things that make someone feel

burned out, when it may not exactly be burn out. Examples: person is in the wrong job. Toxic culture.

Not enough resources to get the work done (might still stay in discipline, just need more resources.)

• Recommended actions, not just a presentation how burn out exists and it's impact, but more on ways

to prevent and address.

• Recommended supports for burn out (internal, local and on-line). Who should approach the person to

have the discussion to ask if they are okay vs. Burnt out? How can we reduce the stigma of talking

about mental or emotional health?

• Signs and symptoms

• Similar to above comment/ overcoming the learned helplessness barrier

• Strategies to reduce nurses' burnout

• Stress management

• Type of errors that correlate to provider burnout


The topics I wish to have covered in the upcoming webinar on

BURN OUT


David Marx, JD

Just Culture Leader & Innovator

Principle, Outcome Engenuity Center

Eden Prairie, MN


March 19, 2020

Just Culture: A 2020 Update

Just Culture A 2020 Update and Case Studies

David Marx, BSE, JD

CEO, The Just Culture Company

www.outcome-eng.com

March 19, 2020

FYI - Two Companies

Do We Live in a Just Culture?

Not everyone’s neurosurgeon, but everyone’s a judge

The Two Camps

Hospital A

If you make a mistake involving the safety of the

patient, raise your hand so that we

can together learn from your mistake.

Hospital B

If you make a mistake involving the safety of the

patient, pack your things, because

you are fired.

Just Culture

• How should we hold each other accountable?

• For our outcomes?

• For our errors?

• For our choices?

• Accountability v. punitive sanction?

• Aspiration v. expectation?

• Perfection v. inescapably fallible?

• No harm, no foul?

• What is a “just” culture?

Just Culture

• When is Just Culture used? • Formally

• Informally

• What’s the procedure? • HR involvement?

• Peer review?

• Who helps the manager?

• What are the actual actions to be taken? • Coaching

• Counseling and disciplinary sanction

Duty and Breach

The Three Duties

The duty to avoid causing

unjustifiable risk or harm

Duty to produce

outcomes

Duty to follow procedural

rules

DON’T

DO

WHAT

To Do HOW

To Do It

Upon arrival on a med-surg unit after surgery, the husband of a patient sees that the hand hygiene rate of nurses entering his wife’s room is hovering around 10%.

The husband raises his concern to the unit manager, who says in response, “We saved your wife’s life. Can’t you just be grateful for what we’ve done?”

Procedure – Nurses’ duty to wash hands

Outcome – Manager’s duty to create safe rate of hygiene

Values – Manager’s tone with family member

Seeing the Three Duties

Human Error

Unintended conduct: where the actor should have done other that what they

did

Knowledge

Knowingly causing harm (sometimes

justified)

A choice where risk is not

recognized, or is mistakenly

believed to be justified

At-Risk Behavior

Purpose

A purpose to cause harm

(never justified)

Reckless Behavior

Conscious disregard of a

substantial and unjustifiable risk

of harm

Just Culture - Simplified

Accept Coach Sanction Sanction Sanction

All Independent of the Actual Outcome

Where We’re At in 2020

Just Culture Implementation

1. Commit to explore the idea (scouts)

2. Learn the concepts and methods (certification)

3. Commit to implement (time, resources, resolve)

4. Benchmark (survey, audits, reporting, outcomes)

5. Scrub policies and procedures (alignment?)

6. Train managers (1 day)

7. Establish the covenant (a unilateral promise)

8. Train staff (2 hours)

9. Feed the change (continuous reinforcement)

10. Measure progress (survey, audits, reporting, outcomes)

We’re Still Seeing Many Hospitals take the Easy Path

• Just Culture Light

• It’s about non-punitive reporting

• It’s only about safety

• It’s only post-event

• It’s about rules

• It’s somewhere in a policy

• It’s an “optional” tool

• Just Culture

• It’s about accountability

• It’s all conduct

• It’s duty and breach

• It’s about values

• It’s hardwired in

• It’s a covenant

Putting You on the Hot Seat

In the nursery at 3:00 am, a highly experienced volunteer falls asleep while rocking a baby to sleep in a rocking chair. The baby falls to the floor, with only minor bruising. The volunteer quickly reported the event.

It is the first time this has occurred in this nursery, although some of the staff have heard of it happening elsewhere.

The Pointy End

A scheduler receives a call from a “friend-of-a-friend” requesting her appointment be moved up to the next day, however the day is already completely booked. Attempting to accommodate the request, the scheduler decides to cancel one of the appointments for the next day and substitutes the “friend.”

The Favor

A manager who had lost a son in the Gulf War, was heard saying to a colleague that she would never hire anyone from a middle eastern country.

A subsequent review of job applications showed a number of qualified middle-eastern candidates that were not brought in for interviews.

Someone Hurt

A new nurse to the OR (watching and learning the processes and practices of her

new employer) storms out of the safety timeout ahead of surgery and right in the

Director of the OR’s office. He blurts out, “Are you kidding me? The anesthesiologist

has her ears covered by headphones. She’s actually dancing a bit, you know,

moving to the beat, nodding her head when people look her way. I looked at

everyone else in the timeout, and no one seemed to notice. They look like Zombies.

Is this how we’re going to treat patient’s here? Do anesthesiologists get a pass? Does

anyone care?”

The Enablers

The chair of department allows a clinician to overbook morning clinic appointments. Average wait times for late morning appointments are over 90 minutes, as compared to 15 for other clinicians. This is in part because many appointments get push to after the doctor’s lunch period. The chair is aware of the wait time data, but takes no to action to force a schedule revision.

Leadership

Safety Culture

Still Much Work to Do

• Getting lawyers, HR professionals and safety professionals on the

same page

• Understanding it’s more about choice (not about error)

• Peer accountability (being my brother’s keeper)

• Leadership accountability and justice

• Precision: making it a covenant

• Understanding it’s CrossFit (very hard work)

58 © 2020 TMIT

National Survey Questions

I would like another webinar on

JUST CULTURE

Very

Strongly

Agree

10

Strongly

Agree

9

Agree

8

Agree

7

Very

Strongly

Disagree

1

Disagree

3

Strongly

Disagree

2

Neutral

6

Neutral

5

Negative

to Neutral

4


JUST CULTURE

58

59 © 2020 TMIT

National Survey Questions

I would like a WEBINAR on

CORONAVIRUS CARE FOR CAREGIVERS

Very

Strongly

Agree

10

Strongly

Agree

9

Agree

8

Agree

7

Very

Strongly

Disagree

1

Disagree

3

Strongly

Disagree

2

Neutral

6

Neutral

5

Negative

to Neutral

4

The topics I wish to have covered in WEBINAR on

CORONAVIRUS CARE FOR CAREGIVERS

59

60

Emerging Threats

Community of Practice

Med Tac Bystander Rescue Care




Founder Med Tac Bystander Rescue Care

Med Tac Bystander Rescue Care March 18, 2020 CareUniversity Webinar #134

Protecting our Seniors


Care of the At Risk & Seniors at Home Coronavirus Response



Care of the At Risk & Seniors at Home Coronavirus Response


Supplies Checklist:

Prescription Medications On Hand: Have at least 90 days of prescription medications on hand. If insurance will allow it, get a 120-day supply. If not, keep track of when they can renew them and then have them filled so they have them on hand.

Over the Counter Medications: Make sure they have over the counter medications for headache, colds, and other ailments they may have not needing prescriptions.

Thermometers: Every home should have a thermometer on hand to so that inhabitants can monitor their temperature whether healthy or sick. Many will get colds or the flu and may be frightened they may have Coronavirus.

Food and Bottled Water: It is important to have food on hand that will not spoil. If power goes out as it can in ordinary circumstances, it may take longer to repair if service personnel are sick. Food that does not require refrigeration or to be stored in freezers needs to be on-hand.

Flashlights and Batteries: (better than candles for reasons of risk) and batteries incase power goes out.

Cleaning and Disinfectant Supplies: Soap and water is very effective to kill the virus because it dissolves fats and the virus has a fat layer. Liquid Soap and water is even better than alcohol disinfectants for both hands and for contact surfaces for killing the Coronavirus. • If alcohol and soap runs out, bleach may be diluted to 1:10 Bleach to Water concentration for

contaminated clothing. • Dilution of 1:50 Bleach to Water concentration fordisinfecting contact surfaces. • Dilution of 1:100 Bleach to Water for skin cleaning. • Having plenty of liquid soap, buckets, and rags are important if caring for someone at home.

Paper towels may be in short supply – rags and towels cleaned in washing machines are safe. Kitchen Rubber Gloves: Two to three pairs of rubber gloves will be good to have on hand if one

has to take care of someone in the home. They should be used for disinfecting the surfaces. Some surfaces will sustain the virus for a few hours. Some, however, can sustain the virus for three to nine days. The virus lasts longer on-porous surfaces like door handles

Full Tank of Gas: If the supply chain is disrupted by illnesses of those transporting or operating gas stations, you may have a hard time getting fuel. We need to be as prepared as we would with a storm or during any natural disaster or emergency.

Reading Materials & Recordings: In the extreme case cable systems and internet providers may go down and seniors should have access to reading materials and recordings to inspire them and maintain hope. Our faith-based communities can provide tremendous support of them here.

Process Checklist: In Case of Emergency - ICE Contact List: Phone numbers and email addresses of friends and

family members who know they are going to be called if an individual experiences an emergency should be on an accessible list. The In Case of Emergency phone numbers should be generated. It should include those who have a Power of Attorney for healthcare and for business issues.

All Caregivers Contact Information: A master list of the doctors, nurse practitioners, pharmacists, and caregiver's office phone numbers, emergency numbers, and addresses should be on an easy to read list.

Local Support Individuals: Names and mobile numbers of friends and family who can pick up supplies for them, transport them, care for them, and check on them.

“If I Get Sick Plan”: A plan of “what if I get sick” directions. For instance – what signs and symptoms should prompt them to call for help. A certain temperature or other developments to drive action.

Hospital of Choice: If an individual has been under the care of a hospital, their medical records are very important to future care. They may identify that hospital or a hospital as a first choice for care.

Medical Power of Attorney: Everyone over the age of 18 will need to execute a medical power of attorney if they are to allow another person to make decisions regarding care if the victim is unable to do so. For instance, college students going to school in another state who are in another state get sick, parents will need one to get medical records.

Regular Expenses & Payment Mechanism: Create a list of regular bills and how to pay them if a person is in the hospital and unable to take care of them.

Regular Home Chores: A list of tasks that must be undertaken if residents become ill and are taken to the hospital should be created. They might include watering indoor and outdoor plants, pet care, and pet care.

Daily Check In Calls: Seniors and those with underlying conditions such as heart, lung, or kidney disease as well as those with immune compromised conditions such as chemotherapy and transplant patients should have someone check in on them if they are alone.

Food Replenishment Process: A process for regular replenishment of food and supplies should be set up.

Meals on Wheels & Support Programs: If seniors and those who qualify can be added to such programs, they should consider such support.

Sick Care Room: A room or section of the home should be identified where a family member can be treated in case, they become ill. This is whether they get the Coronavirus, a cold, or the flu.


Can We Still Have Fun Through the Curve? Coronavirus Response


Social Distance Means Distance

and No Mutual Contact Surfaces


Speakers and Reactors

Dr. David Marx Dr. Charles Denham Arlene Salamendra Heather Foster


Voice of Patient and Family

Arlene Salamendra

Former Board Member and Staff Coordinator, Families Advocating Injury

Reduction (FAIR)

TMIT Global Patient Advocate Team Member

Plano, IL


February 20, 2020


ADDITIONAL

RESOURCES

© 2006 HCC, Inc. CD000000-0000XX 67 © 2020 TMIT

In The News …

Recent Safety Scandals Suggest Healthcare

Leaders Haven’t Learned Lessons

https://www.modernhealthcare.com/safety-quality/recent-safety-scandals-suggest-healthcare-leaders-havent-learned-lessons https://www.modernhealthcare.com/safety-quality/recent-safety-

scandals-suggest-healthcare-leaders-havent-learned-lessons

November 09, 2019

© 2006 HCC, Inc. CD000000-0000XX 68 © 2020 TMIT

In The News …

68


Dec 10, 2018

These were big stories with no small

implications. If these scandals were the

work of only a few selfish individuals,

most HR departments could resolve them.

Unfortunately, the problems are endemic

and deeply embedded in medical culture.

When it comes to the questionable ethics

of accepting money and perks from drug

and device companies, doctors and

hospital administrators routinely look the

other way.

Source: Forbes https://www.forbes.com/sites/robertpearl/2018/12/10/shame-scandal/#785cc45c6807

Shame, Scandal Plague

Healthcare Providers In 2018

In 2005, Dr. Sharon Levine designed and orchestrated the industry’s strictest conflict-of-interest policy, a

program that defied the doomsday predictions of many doctors. Only two of the 5,000 physicians working

in the medical group at the time left as a result of the new policy. (Kaiser conflict of interest policy)

https://www.forbes.com/sites/robertpearl/2018/12/10/shame-scandal/#785cc45c6807



© 2006 HCC, Inc. CD000000-0000XX 69 © 2020 TMIT

Healthcare Innocence Project

69

Doctors, Defamation, and Damages: Medical Practitioners Fighting Back.

© 2006 HCC, Inc. CD000000-0000XX 70 © 2020 TMIT

In The News …

70

1. Prohibit doctors from accepting anything at all from drug or device companies.

Conflict of Interest Code of Conduct

Source: Kaiser Conflict-of-Interest Policy, Forbes

2. Form an ethics committee to address any concerns doctors may have.

3. Direct all research funding, regardless of the source, to the institution and not to individuals.

4. Require all providers to disclose any past payments, prior to the policy’s implementation.

© 2006 HCC, Inc. CD000000-0000XX 71 © 2020 TMIT

In The News …

Paying Attention To Complaints

Can Protect Nurses From Violence

SOURCE: https://scienmag.com/paying-attention-to-complaints-can-protect-nurses-from-violence/

February 20, 2020

Complaints from patients and their family members could signal

future violence against nurses and should not be ignored,

suggests new research from the University of British Columbia.

“Health care workers are four times more likely to face physical

and emotional abuse on the job as workers in other

professions,” says study author Farinaz Havaei, an assistant

professor of nursing at UBC. “Other studies have shown that

addressing patient complaints contributes to positive patient

outcomes. Now, for the first time, we have evidence that acting

on these complaints can also protect nurses’ safety.” The B.C.

Nurses’ Workload Impact Study, comparing workload factors

(such as how many tasks nurses say they left unfinished during

their last shift and how often they experienced heavy

workloads) with patients’ complaints and reports of emotional

and physical abuse towards nurses. Results showed a strong

correlation between patients’ complaints and violence.

“What we think happens is a spiral of

aggression is created. Patients get

frustrated by what they see as poor-quality

performance–often caused by factors such

as staff shortages and large workloads,”

“They respond initially with complaints, and

if those complaints aren’t addressed in a

timely manner, they can then escalate into

more serious acts of aggression.

https://scienmag.com/paying-attention-to-complaints-can-protect-nurses-from-violence/

















© 2006 HCC, Inc. CD000000-0000XX 72 © 2020 TMIT

In The News …

Quality Often An Afterthought

For System, Hospital Boards

SOURCE: Modern Healthcare February 8, 2020

February 8, 2020

The article by Maria Castellucci opens with “Too few boards

appreciate their responsibility to oversee quality, but safety issues at

some high-profile organizations should motivate boards to do more”.

The article cites Dr. Gary Kaplan of Virginia Mason and other leaders

such as former CEOs including Nancy Schlichting Henry Ford in

Detroit. The patient safety crisis at Johns Hopkins All Children’s

Hospital was discussed in the context of board involvement.

Beth Daley Ullem, a leading governance board expert with IHI is cited:

“When I talk with boards, a lot say they get hit with too much data”.

She recommends boards ask leadership to dive into one or two areas

in which the organization is facing challenges and then explain some

approaches to address them. “That tends to help facilitate a

confidence about management’s approach to identifying,

understanding and coming up with a plan to tackle a problem”.

73 © 2020 TMIT

Meaningful Use is dead. Long live something better! In the News: Med Tac Updates

Source: Campus Safety Nov/Dec Issue - https://www.campussafetymagazine.com/public/med-tac-training-bystanders/

Nov/Dec 2018 Issue

© 2006 HCC, Inc. CD000000-0000XX 74 © 2020 TMIT

Meaningful Use is dead. Long live something better! Med Tac Slides and Articles in RESOURCES SECTION

74

Med Tac Articles: Campus Safety Magazine

© 2006 HCC, Inc. CD000000-0000XX 75 © 2020 TMIT

In The News …

https://www.modernhealthcare.com/safety-quality/hospitals-fall-short-patient-safety-goals-20-years-after-err-human

November 09, 2019

Hospitals Fall Short of Patient Safety

Goals 20 Years after 'To Err Is Human'

© 2006 HCC, Inc. CD000000-0000XX 76 © 2020 TMIT

In The News …

Source: https://www.modernhealthcare.com/safety-quality/hospitals-fall-short-patient-safety-goals-20-years-after-err-human

November 09, 2019

Hospitals Fall Short of Patient Safety

Goals 20 Years after 'To Err Is Human'

© 2006 HCC, Inc. CD000000-0000XX 77 © 2020 TMIT

In The News …

77


Nearly 200 investigations are underway at major academic

centers. Critics fear that researchers of Chinese descent are

being unfairly targeted.

The N.I.H. and the F.B.I. have begun a vast effort to root out

scientists who they say are stealing biomedical research for

other countries from institutions across the United States.

Almost all of the incidents they uncovered and that are under

investigation involve scientists of Chinese descent, including

naturalized American citizens, allegedly stealing for China.

Seventy-one institutions, including many of the most prestigious

medical schools in the United States, are now investigating 180

individual cases involving potential theft of intellectual property.

The cases began after the N.I.H., prompted by information

provided by the F.B.I., sent 18,000 letters last year urging

administrators who oversee government grants to be vigilant.

Vast Dragnet Targets Theft

of Biomedical Secrets for China 11-09-19

© 2006 HCC, Inc. CD000000-0000XX 78 © 2020 TMIT

In The News …

2019 National Drug Threat Assessment DEA - US Justice Department

https://www.modernhealthcare.com/safety-quality/recent-safety-scandals-suggest-healthcare-leaders-havent-learned-lessons https://www.modernhealthcare.com/safety-quality/recent-safety-

scandals-suggest-healthcare-leaders-havent-learned-lessons

December 2019

The 2019 National Drug Threat Assessment (NDTA)a

is a comprehensive strategic assessment of the

threat posed to the United States by domestic and

international drug trafficking and the abuse of both

licit and illicit drugs. The report combines federal,

state, local, and tribal law enforcement reporting;

public health data; open source reporting; and

intelligence from other government agencies to

determine which substances and criminal

organizations represent the greatest threat to the

United States.

© 2006 HCC, Inc. CD000000-0000XX 79 © 2020 TMIT

Meaningful Use is dead. Long live something better! High Impact Care Hazards to Patients, Students, and Employees

79

Published November 11, 2019 https://www.campussafetymagazine.com/news/inadequate-

placement-of-aed-and-bleeding-control-gear-could-cost-you/

80 © 2020 TMIT

Meaningful Use is dead. Long live something better! YouTube Patient Safety Briefings

Active Shooter Events in Healthcare

https://www.youtube.com/watch?v=qSs

WAs5JJBw&feature=youtu.be

Med Tac Bystander Care Training

https://www.youtube.com/watch?v=2lM

0jh4qCQU&feature=youtu.be

Opioid Overdose Crisis 2019 Update

https://www.youtube.com/watch?v=vyC

xQWxaEqE

YouTube TMIT Patient Safety Briefings

Sudden Cardiac Arrest

https://www.youtube.com/watch?v=qd

XW5WxDDY8&feature=youtu.be

Med Tac Lifeguard-Surf Program

https://www.youtube.com/watch?v=G1

V8s7LWL6M&feature=youtu.be

Rapid Response Teams

https://www.youtube.com/channel/UCC

coR25LxSltmrdRqyCQ7fA/

Just Culture: A 2020 Update and Case Studies

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Transcript of Just Culture: A 2020 Update and Case Studies